Meeting National Standards for Clinical Audit: NHS Litigation Authority Level 3 Helen Clarke Clinical Audit / NHSLA Lead Mid Essex Hospital Services Trust

NHS Litigation Authority & Risk Management Standards MEHT approach to assessment Criterion for Clinical Audit Performance issues

NHS Litigation Authority (NHSLA) Clinical Negligence Scheme for Trusts; Liabilities to Third Parties Scheme; and Property Expenses Scheme1. Risk Management Standards 5 standards, each with 10 criteria Designed to focus attention on key safety & quality areas. 1 NHSLA (2012) NHSLA Risk Management Standards for NHS Trusts providing Acute, Community, or Mental Health & Learning Disability Services and Non-NHS Providers of NHS Care 2012-13

Assessment levels Level 1 2 yearly 10% Level 2 3 yearly 20% Requirement at assessment Frequency Discount Level 1 Policy The process for managing risks has been described and documented in a formally approved document 2 yearly 10% Level 2 Practice The process for managing risks is in use 3 yearly 20% Level 3 Performance The process for managing risk is working across the entire organisation - where deficiencies have been identified through monitoring, action plans have been drawn up and changes made to reduce the risks. 30%

Mid Essex Hospitals Services Trust Acute Trust with supra-regional St Andrews Plastics & Burns Unit Just under 600 beds 3500 plus WTE staff NHSLA Level 2 achieved November 2008 NHSLA Level 3 assessment November 2011 Assessment preparation co-ordinated within Clinical Audit Department

Acute Services: our approach 1 Identify Executive and Operational Lead(s) 2 Review policy against requirements including monitoring process 3 Develop audit plan for each criterion

Acute Services - our approach to level 3 4 Audit findings reported to identified committee 5 Action plan developed to address any deficiencies 6 Progress monitored at subsequent meetings until closed

NHSLA Risk Management Standards 2012–13 Std  1 2 3 4 5 Criterion  Governance Learning from Experience Competent & Capable Workforce Safe Environment Acute, Community and Non-NHS Providers Risk Management Strategy Clinical Audit Corporate Induction Secure Environment Supervision of Medical Staff in Training Policy on Procedural Documents Incident Reporting Local Induction of Permanent Staff Violence & Aggression Patient Information & Consent High Level Risk Committee(s) Concerns & Complaints Local Induction of Temporary Staff Slips, Trips & Falls (Staff & Others) Consent Training Risk Management Process Claims Management Risk Management Training Slips, Trips & Falls (Patients) Maintenance of Medical Devices & Equipment Risk Register Investigations Training Needs Analysis Moving & Handling Medical Devices Training 6 Dealing with External Recommendations Analysis & Improvement Risk Awareness Training for Senior Management Hand Hygiene Training Screening Procedures 7 Health Records Management Learning Lessons from Claims Moving & Handling Training Inoculation Incidents Diagnostic Testing Procedures 8 Health Record- Keeping Standards Best Practice - NICE Harassment & Bullying The Deteriorating Patient Transfusion 9 Professional Clinical Registration National Confidential Enquiries & Inquiries Supporting Staff Clinical Handover of Care Venous Thromboembolism 10 Employment Checks Being Open Stress Discharge Medicines Management 2.1 Clinical Audit

Criterion on Clinical Audit (1of 2) Level 1 - Policy a) duties b) how the organisation sets priorities for audit, including local and national requirements c) requirement that audits are conducted in line with the approved process for audit

Criterion on Clinical Audit (2 of 2) d) how audit reports are shared e) report format including methodology, conclusions, action plans etc. f) how the organisation makes improvements g) how the organisation monitors action plans and carries out re-audits h) how the organisation monitors compliance with the above

Monitoring compliance with the Trust’s Clinical Audit Policy Sample of clinical audit projects reviewed against specific measures; Report submitted to Clinical Audit Group (CAG) for approval & development of action plan; Progress monitored at subsequent CAG meetings; and Key findings & learning disseminated.

Audit Measures / Performance Compliance threshold Standard met 2011 2012 1 Priority level identified 95% 2 Factors influencing proposal identified 3 Proposal form completed with identified Project & Clinical Leads 4 a. Project standards based 90% b. Standards identified 5 Directorate Audit Lead approval

Audit Measures / Performance Compliance threshold Standard met 2011 2012 6 Audit completed / CA informed 95% 7 Report submitted to CA 8 Appropriate report template 75 % 9 Audit findings disseminated 90% 10 Evidence action plan developed 11 Evidence of implementation 12 Plan for re-audit 50%

Actions to address deficiencies Robust gatekeeping by Clinical Audit Department; Directorate Audit Lead role; Increased clarity for about role; Training commissioned; Software purchased; Annual review, performance data to Clinical Audit Group & Directorates.

The future ….. Cultural shift Impact of regulatory, safety & quality improvement agendas: Quality Accounts & HQIP / National Clinical Audit Programme Care Quality Commission Monitor CQUINs Medical Revalidation NHSLA consultation

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